Provider Demographics
NPI:1104982016
Name:MILLER, MARK D (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15142 ROSARIO RD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-5439
Mailing Address - Country:US
Mailing Address - Phone:270-889-3686
Mailing Address - Fax:
Practice Address - Street 1:1211 W BROADWAY UNIT 106
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2082
Practice Address - Country:US
Practice Address - Phone:270-885-0165
Practice Address - Fax:270-886-2224
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY68611223D0004X, 204E00000X, 1223S0112X
TX360871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223D0004XDental ProvidersDentistDental Anesthesiology
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60068616Medicaid
KY64068612Medicaid
KY60068616Medicaid
KY1724801Medicare ID - Type Unspecified